Blacks and bypass surgery: Some puzzling findings

Black men who have heart attacks are less likely than white patients to undergo bypass surgery, a new study has found. At the same time, they have a better survival rate -- at least in the short term.

These results suggest that the differences in treatment are not simply due to discriminatory attitudes on the part of doctors, the researchers said yesterday. In fact, the puzzling findings could mean that blacks receive appropriate surgical treatment while whites receive too much, they added.

"I'm pretty satisfied that what we have here is not the issue of access" to high-tech medical care, said Dr. Jennifer Daley, of the Brockton/West Roxbury (Mass.) Veterans Affairs Medical Center. "I can't say that it's not a matter of physicians' attitudes" in prescribing one treatment or another," she added. "But it's a more complicated question than it would first appear."

Dr. Eric D. Peterson, who led the study, said, "I think we have narrowed . . . down [black-white treatment differences] from a vague idea to a few specific possibilities, and the one we need to focus on is the patient-physician interaction."

Duke University's Dr. Peterson, who presented the study at the American Heart Association in New Orleans, said there is some evidence that blacks are more cautious about agreeing to surgery or other aggressive forms of treatment. That remains unclear, but Dr. Peterson said, "it may be that black patients, whose doctors tend to be white, are less likely to feel a rapport that would lead them to opt for a riskier treatment."

The better survival of black patients during the first year or so might argue that whites inappropriately went through risky surgery. However, as Dr. Peterson pointed out, the survival difference disappeared after two years . If the trend continues and the condition of white patients improves, the argument might be made that they received riskier treatments but those that improved the long-term prognosis.

Dr. Daley mentioned some other possible explanations for the confusing outcome:

* Previous studies show that some blacks wait longer before seeking treatment for heart attack symptoms.

"What if the blacks who had the most serious heart attacks never got to the hospital? Then those who did . . . would be a healthier patient group," she said.

* Heart disease, caused by fatty obstructions in the blood vessels supplying the heart, may manifest itself somewhat differently in blacks and whites, said Dr. Daley. The anatomy of the obstructions could slightly favor survival in blacks who have heart attacks.

* Finally, the study could not exclude the possibility that physicians, consciously or otherwise, were less likely to perceive blacks as benefiting from aggressive treatment.